Barnes County Long Term Recovery Rebuild and Retain Application Attention Applicants: Distribution of funds will be considered for safe, sanitary, secure, and essential living space. Applicants must have owned their flooded home and will reside in their re-built home or relocate within the flood affected county. We also require a Retention agreement to be signed by the owner of the residence. Application deadline is December 7 th, 2012. Families must fall between 100-300% of Annual Federal Poverty Guidelines *refer to income eligibility chart MUST Mail application to: Phone: 701-271-3288 Barnes Long Term Recovery Committee Email: jsnyder@lssnd.org C/O Lutheran Social Services of ND 1720 3 rd Ave North Fargo ND, 58102 Name of Applicant (print): Date of the application (MM/DD/YYYY): / / FEMA # Date of Birth (MM/DD/YYYY): / / Personal ID: (such as Driver s License) Pre-Flood Address Did applicant formerly own? Home (Single Family Dwelling) Mobile Home/Trailer Number of persons residing in pre-flood household: Adults: Dependent Children: Current Address Page 1 of 7
Current Mailing (if different from above) Applicant s phone# Alternate phone# Email address Does applicant current reside at flooded home? Yes No Number of persons residing in current household: Adults: Dependent Children: Household s 2010 annual net income $ (provide 2010 tax return information) Estimated Value of any lost property $ Any household member has a documented disability Yes No Resources Received: Date Received FEMA $ / / SBA Loan $ / / BND Loan $ / / Flood Insurance $ / / State Individual & Family Grant (IFG) $ / / Hazard Minimization Grant $ / / Area Recovery Fund $ / / Other Awards received $ / / *The following Information is required but will not be determining factor or affect grant award I was displaced from my home which I owned. I suffered substantial or complete loss or damage to my home which I owned. My home was condemned due to property loss. I resided in a mandatory evacuation zone. I sustained significant tree removal and debris cleanup costs. I purchased and will reside permanently in a location other than my flooded home. I have rebuilt and will sell or use as rental property. Page 2 of 7
Signature I certify and declare to the best of my knowledge and belief that the information I have provided is true, accurate, and complete, and that I lack the financial resources necessary to complete my recovery from the spring 2011 flooding. Home owner Signature: Print: Date: Home Owner Signature: Print: Date: $ Amount of unmet needs Office Use Only $ Amount for materials necessary for safe, sanitary, secure, essential living Page 3 of 7
CONSENT AND RELEASE I,, hereby authorize the Barnes Long Term Recovery Committee to share any of my information in its possession, including but not limited to my name, address, other personal information and the type of assistance I am receiving with other disaster relief and voluntary organizations. If you wish to limit this release to specific information, please specify the information that may be released. I understand that I may revoke this consent at anytime by contacting Barnes Long Term Recovery Committee except when action has already been taken to obtain and/or release such information to organizations providing resources. My signature on this release indicates that I have read the above, or had it read to me, and that I understand the terms and conditions. I have also had the opportunity to ask any questions. I am also signing this release on behalf of my children that are under the age of (18). Signature Home Owner (s) Date CONFIDENTIALITY AGREEMENT Any information provided by the client(s) to the organization s staff or volunteers is to be kept in the strictest of confidence. None of the information exchanged about donor individuals, donor organizations, or client cases will be discussed outside of the official interview and decision-making process of the Organization, except as authorized above. Signature Barnes Long Term Recovery Representative Date Page 4 of 7
Case Number: Barnes Point System Rebuild and Retain Chairperson Potential Points Point Value $1,000 Criteria Potential Points Uninsured/FEMA Denied 3 Documented Physical/Mental Health Issues 2 Extent of Loss 4 Up t o$5,000 1point $5,001-$10,000 2points $10,001-$20,000 3points $20,000 damages over 4points Extenuating Circumstances 3 Income Level 3 Very low income 3 points Low Income 2 points Moderate Income 1 point Total Potential Points 15 Total Committee Approved Points Approved Dollar Value Page 5 of 7
Barnes County Rehabilitation and Citizen Retention Grant Agreement Date: Amount Received: This agreement applied to the following individual(s) and their property: Name: Address: City, State, Zip: Telephone: For the value received, the undersigned promises to pay to the order of the Barnes Unmet Needs Committee, the principal sum of without intent if the recipient(s) convey or discontinues occupancy of the property within one (1) year. The above-stated principal sum shall upon one (1) year from this date automatically reduce to 50% if the recipient(s) conveys or discontinues occupancy of the property. If the undersigned conveys or discontinues occupancy of the property before two (2) years of, the principal sum, or balance thereof as reduced hereinabove, as the case may be, shall become due and payable. IN WITNESS WHEROF, the note has been duly executed by the undersigned, as of the date set forth above. Recipient #1 Signature Recipient #2 Signature (if applicable) Unmet Needs Committee Member Page 6 of 7
2012 Barnes County Income Eligibility Guidelines Household size Very Low Income(3) 160% of Very Low Income Low Income(2) 140% of Low Income Moderate Income(1) 120% of Moderate Income 1 $ 13,100 $ 20,960 $ 21,850 $ 30,590 $ 34,900 $ 41,880 2 $ 15,000 $ 24,000 $ 24,950 $ 48,930 $ 39,900 $ 47,880 3 $ 16,850 $ 26,960 $ 28,050 $ 39,270 $ 44,900 $ 53,880 4 $ 18,700 $ 29,920 $ 31,150 $ 43,610 $ 49,850 $ 59,820 5 $ 20,200 $ 32,320 $ 33,650 $ 47,110 $ 53,850 $ 64,620 6 $ 21,700 $ 34,720 $ 36,150 $ 50,610 $ 57,850 $ 69,420 7 $ 23,200 $ 37,120 $ 38,650 $ 54,110 $ 61,850 $ 74,220 8 $ 24,700 $ 39,520 $ 41,150 $ 57,610 $ 65,850 $ 79,020 Page 7 of 7